Which information category includes History of Present Illness, Review of Systems, Past Medical, Past Surgical, Family, and Social History, Medications, and Allergies?

Which information category includes History of Present Illness, Review of Systems, Past Medical, Past Surgical, Family, and Social History, Medications, and Allergies?

• A. Objective Information
• B. Subjective Information
• C. Plan
• D. Assessment

Answer: (B)

In medical documentation, items that come from the patient’s own report during the interview are categorized as subjective information. History of Present Illness, Review of Systems, Past Medical History, Past Surgical History, Family History, Social History, medications, and allergies are all information the patient or their caregivers provide about symptoms, conditions, and exposures. They reflect the patient’s perspective and history, not measurements or observations made by the clinician. That’s why they belong in the subjective portion. In contrast, objective information consists of data obtained through examination and testing (like vitals and physical findings), the assessment is the clinician’s diagnostic impression, and the plan outlines intended actions.

In medical documentation, items that come from the patient’s own report during the interview are categorized as subjective information. History of Present Illness, Review of Systems, Past Medical History, Past Surgical History, Family History, Social History, medications, and allergies are all information the patient or their caregivers provide about symptoms, conditions, and exposures. They reflect the patient’s perspective and history, not measurements or observations made by the clinician. That’s why they belong in the subjective portion. In contrast, objective information consists of data obtained through examination and testing (like vitals and physical findings), the assessment is the clinician’s diagnostic impression, and the plan outlines intended actions.